Provider Demographics
NPI:1265848667
Name:POLECASTRO, MARC (LMT)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:POLECASTRO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 E NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3364
Mailing Address - Country:US
Mailing Address - Phone:847-577-2660
Mailing Address - Fax:847-577-2661
Practice Address - Street 1:668 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3364
Practice Address - Country:US
Practice Address - Phone:847-577-2660
Practice Address - Fax:847-577-2661
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.011678225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL227.011678OtherLICENSED MASSAGE THERAPIST